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SANITARY PERMIT APPLICATION <br /> V �A COUN <br /> In accord with ILHR 83.05,Wis.Adm.Code I I r. <br /> STATE,,,SSSANITAR ERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than / '�(?1� 19 gq <br /> 8'fi x 11 inches in size. ❑ C lack if revisi to previous application <br /> -See reverse side for instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Tom Fcvthe2 SOW SW %, S 21 T40 , N, R 14 E (o Ill <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 2397 County Raod A <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Spooner, W7 54801 715 635-7878 <br /> Check one CITY NEAREST ROAD <br /> If. TYPE OF BUILDING: <br /> ( ) State Owned o VILLAGE: Scott Banoch Road <br /> 1:1 Public ® _L_ PA <br /> 1 or 2 Fam. Dwelling-#of bedrooms RCELTAXNUM ER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) �.I o'�'— - <br /> 1 ❑ Apt/Condo <br /> cD <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify • <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. ❑ New 2. ® Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit# Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 ® Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERS.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 499 643 .47 NA 94.9 Feet 97.3 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New istin Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 800 800 1 Skaw <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature: Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Rubaha2m �ilv ur /� 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.U. Box 514 Sihen, W1 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> 7ed 'o <br /> Disapproved Sanitary Permit Fee(tncludes Groundwater ae ssue Issuin Agent Signature(No Stamps) <br /> appOwner Given Initial a Surcharge Fee) , l{/ <br /> Adverse Determinati n - /60' 00 ��I I � l <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />